Trump Freezes 'Evidence-Based' Program For Addiction And Mental Health Treatments

In the middle of an opioid epidemic.

LENA H. SUN AND JULIET EILPERIN, THE WASHINGTON POST

15 JAN 2018

Federal health officials have suspended a program that helps thousands of professionals and community groups across the country find effective interventions for preventing and treating mental illness and substance-use disorders.

The National Registry of Evidence-based Programs and Practices (NREPP) is housed within the Health and Human Services Department's Substance Abuse and Mental Health Services Administration (SAMHSA).

The registry, which was launched in 1997, offers a database of hundreds of mental health and substance abuse programs that have been assessed by an independent contractor and deemed scientifically sound.

Getting a program or therapeutic approach included in this registry amounts to receiving federal recognition as an evidence-based practice. Mental health and addiction specialists say they rely on this database as a key source for finding appropriate and effective therapies.

Since 2015, the registry has also included evidence that certain interventions do not work, which helps practitioners avoid wasting resources on those programs.

Administration officials confirmed that the contract for running the database has been terminated. A new entity will take over the program's duties. A director for that group was announced Monday, but no other staff members are in place.

Agency spokesman Brian Dominguez said Wednesday that the new entity is "working closely" with other parts of the agency to "institute an even more scientifically rigorous approach to better inform the identification and implementation of evidence-based programs and practices."

Officials did not give specifics about how the new approach will work, when it will launch or whether existing validated programs will be included.

Agency officials froze the existing website in September, and no new postings have been added, according to mental health advocacy groups. As a result, about 90 new programs that have been reviewed and rated for their scientific merits since September are not available to the public, they said.

"I know there are quite a number of new studies that could be breakthrough strategies for prevention of psychiatric disorders, opiate addictions, autism spectrum disorders — any number of things," said Dennis Embry, president of Paxis Institute, a for-profit Arizona organization that helps communities identify evidence-based practices for the prevention of psychiatric disorders.

Asked about the freezing of the website, agency spokesman Christopher Garrett said Wednesday that the agency's job is to "lead the efforts to rapidly institute evidence-based practices in all behavioral health treatment programs" in the country.

"The federal government should not be in the business of having a single contractor determine winners and losers in behavioral health care," he said.

In a statement late Thursday, SAMHSA's top official criticized the registry, calling it a "poor approach to the determination of" evidence-based practices.

For most of its existence, the database "vetted practices and programs submitted by outside developers — resulting in a skewed presentation of evidence-based interventions, which did not address the spectrum of needs of those living with serious mental illness and ­substance-use disorders," said Elinore McCance-Katz, the agency's new assistant secretary for mental health and substance use.

As currently configured, the program "often produces few to no results" when common search terms such as "medication-assisted treatment" or illnesses such as schizophrenia are entered, she said.

While agency officials work on the new approach, the registry will remain online, officials said.

The possibility of losing the registry, or of having it essentially frozen, has outraged mental health professionals and members of Congress. Mental health professionals are especially concerned that moving the process in-house could politicize the process of evaluating programs.

"NREPP is one of the most important tools we have. Nobody has a financial stake," said Catherine Tucker, president of the Association for Child and Adolescent Counseling, a membership organization for counselors who work with young people.

She added: "It's an impartial, nonpartisan, trustworthy source that represents thousands and thousands of hours of work."

That responsibility will now be led by a new entity within the agency, the National Mental Health and Substance Use Policy Laboratory, or Policy Lab. The lab was authorized under a sweeping health-care law passed in 2016.

Known as the 21st Century Cures Act, the law increased funding for research into cancer and other diseases, and also made changes to the mental health system, including the creation of the new assistant secretary for mental health and substance use position at SAMHSA.

Trump's nominee for that position, McCance-Katz, a psychiatrist and former medical director at SAMHSA, was confirmed last summer. In testimony to Congress last month, she said the primary focus of the Policy Lab is to "periodically review programs and activities" relating to the diagnosis, prevention, treatment and recovery from mental illness and ­substance-use disorders.

The lab will also identify programs or activities "that are duplicative and are not evidence-based, effective or efficient," she said.

The Policy Lab will also play a role in awarding grants to state and local governments, educational institutions and nonprofits to develop evidence-based interventions, she said.

The move has unsettled lawmakers from both parties.

Sen. Rob Portman (R-Ohio), who included a provision in the 1997 Drug-Free Communities Act that requires that any prevention programs authorized by the law be certified under the registry, said in a statement that when it came to the suspension, "I'm concerned and looking into it."

"I've long believed we must use federal funds for evidence-based programs that work and we must continue to make this a priority," Portman said.

Rep. Grace Meng (D-N.Y.), a member of the House Appropriations Committee, sent a letter to McCance-Katz just last week praising the registry as a "critical tool in fighting addiction."

Earlier this week, "I was shocked to learn that the NREPP contract has been terminated as an opioid epidemic continues to shake our nation," Meng said. She has sent another letter to ask why.

She noted that every mention of the registry in the agency's budget plan indicates that it will be funded through September 2018.

"I'm determined to find out why SAMHSA has made such a mind-boggling decision," she said.

The agency has been criticized by some outsiders as paying insufficient attention to the treatment needs of the seriously mentally ill. One of its most ardent detractors was former congressman Tim Murphy (R-Pa.), who pushed for changes such as the new assistant secretary position at SAMHSA during bitter hearings several years ago.

The registry itself is not without controversy. In July, a paper in the International Journal of Drug Policy said the database was not "weeding out" ineffective programs.

Between September 2015 and January 2017, the paper noted, 113 interventions were added to the registry. Of these, the evidence for 14 percent of them consisted of a single, non-peer-reviewed report, and 45 percent of them relied primarily on a single peer-reviewed article.

Amy Sechrist, a certified prevention specialist at Compass Mark, a Pennsylvania nonprofit that works to reduce substance addictions, said that while the ­registry has had its problems, "we need leadership and clearinghouses for interventions that work."

"We are always communicating to our clients, the public and legislators that prevention is a science," said Sechrist, whose group uses interventions in the database.

"We look to SAMHSA for prevention science," she added, saying that if it stops offering it, that undermines how Americans view the programs her agency and others offer.

Agency officials notified the contractor Dec. 28 that they were terminating the contract for the registry "for the convenience of the government," according to an email sent by the contractor to program participants.

All activities have been suspended, said the contractor, Development Services Group Inc. of Bethesda, Md.

Scott Bryant-Comstock, president and chief executive of the Children's Mental Health Network, said he spoke to a senior agency official about the termination but didn't get clear answers about what strategies will be considered "evidence-based" under a new system.

Referring to the acrimonious House hearings on mental health that led to the creation of the Policy Lab and other agency changes, he said that "for advocates, it's really important to ensure this doesn't just become solely focused on the seriously mentally ill and doesn't take into account some of the prevention things."